25 June 2007

I spent a lot of time postponing the inevitable last night. It seemed like every patient was a severely demented octogenarian, non-verbal and non-ambulatory, either septic or with a lower extremity long-bone fracture. (Or, in some cases, both!) Blessedly, most came in with valid DNR papers, so I did not have to pursue heroic measures, but (as I have had to explain to several hospitalists) "Do Not Resuscitate" does not mean "Do Not Treat." So I went and tanked them up with fluids, cultured them from stem to stern, poured in gorilla-cillin and got the relevant consults, all the while shaking my head at the sheer futility of it all. It could have been worse -- the families were all either absent or present and realistic -- no frantic insistence upon unreasonable interventions. But it seems like even the most reasonable families still have a problem withholding antibiotics. They're down with the notion of "no life support" but "just let Granny die" seems too cold for them, especially when contrasted with the seemingly non-invasive IV fluids and antibiotics.

I was lucky, though, that admidst the wreckage there was one beautiful shiny satisfying "Emergency Medicine" case. As good as a Nursemaid's Elbow. Healthy, happy patient, grateful parents, ER doc looking like a hero.Yes, she swallowed a dime. No, she's going to be fine -- 99% of them pass within the week. If you like you can examine her stool, but realistically, you can do nothing at all as long as she has no symptoms. If you like you can follow up for a repeat x-ray at her pediatrician's office in a week, but even that is not necessary in the absence of symptoms.

That case put the smile on my face to get me through the rest of the shift.

9 comments:

But it seems like even the most reasonable families still have a problem withholding antibiotics.

Are you thinking they are unreasonable about the antibiotics? I am unsure how I would feel, I guess the circumstances would matter -- how long does she have without them, what infection risk does she bear, would the course of the infection cause discomfort, etc.

It's the immediacy version of not treating a 75 year-old with early stage prostate cancer, isn't it?

Just to answer your questions, I am referring to patients who already have an infection, who will certainly die without antibiotics, whose death due to the infection would generally be without suffering, and who can easily be treated with antibiotics.

I don't make a fuss about the antibiotics because I am careful not to project my values onto the families. When I see a moaning, unresponsive, moribund patient, whose quality of life prior to coming in was near nil, I have two instinctive reactions:1. She's going to die2. She ought to dieSo my personal instinct is to administer morphine and keep her comfortable.

However, families typically see the patient differently, not surprisingly. They usually view the patient as if she were the person whom they had loved (prior to dementia stealing her away), and their instinct is to treat her and keep her alive. I don't think it's unreasonable, and in fact it is a near universal response. But from my perspective, it's wrong. These folks have reached the end of their natural life and should be allowed to pass peacefully.

But families (and doctors) still have the reflex that if you can treat it, you must.

It's interesting here that I am contradicting myself from the original post -- "Do Not Resuscitate " does not mean "Do Not treat" -- but there is a point where "Do Not Treat" is a reasonable option and even the best option. But I guess the national conversation about dying hasn't gotten to the point that people are comfortable with that yet.

There are "reasonable" families out there who will forego the use of antibiotics in these cases - but it is up to us to initiate the discussion that, in the appropriate circumstances, it is permissable to do so.

Obviously, such a discussion is best conducted by the patient's primary doc. But a covering doc or an ER doc can do it also if they can take a few minutes to find out what the family's realistic expectations are for this patient.

I've had this discussion with family members in a coverage setting, and I've encountered the response, "You mean it's OK to do that?" - to not use antibiotics.

But we can't expect the family to have the insight to make the logical leap to that conclusion - it's on us to bring it up in appropriate settings.

you are right, but my experience is that when I bring the idea up, there is usually resistance. It's hard for me to tell if it is just that the family is only just coming to grips with the situation, or it is a value-based decision. Also, I am usually under significant time pressure. So I tend not to fight it, unless it's a *really* clear-cut case.

"Blessedly, most came in with valid DNR papers, so I did not have to pursue heroic measures, but (as I have had to explain to several hospitalist)..."

Interesting shadow I have never ever seen an ER doc manage a patient beyond the ER doors yet alone see them on the floor. I can tell you doozies about ER docs who have mismanaged DNR/DNI (from ignoring and intubating to treating as comfort care). Just remember, us clueless hospitalists actually manage the pt for more than a couple of hours.

I'll throw this out there in reaction to this passage: "But it seems like even the most reasonable families still have a problem withholding antibiotics. They're down with the notion of "no life support" but "just let Granny die" seems too cold for them, especially when contrasted with the seemingly non-invasive IV fluids and antibiotics."

A few years ago my mother-in-law was terminally ill, and had decided to not be resuscitated. One weekend she got very ill, for lack of a better term, and asked to go to the hospital --- where after assessing her the E.R. doctor asked us what we wanted to do. Our answer was to honor her last instructions --- to go to the hospital, and she was buffed up with fluids, antibiotics, etc. during a one week stay. Two weeks after being discharged, she deteriorated to the same state she was in when she asked to go to the hospital. This time she did not ask to go, and died a couple of days later. Why put her through that? Because she wasn't ready to die, when she asked to go to the hospital --- three weeks later she was ready. So it may not always be familial reluctance, but rather familial desire to honor the patients wishes, i.e. honor her right to self determination.

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

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